Clinical Review Nurse

At Blue Shield of California, we're seeking an experienced Senior Clinical Utilization Review Nurse to join our Facility Compliance Review team. This role is ideal for a highly skilled professional who can ensure medical necessity and billing standards are met.Key Responsibilities:Conduct retrospective utilization reviews and first-level determination...

About the RoleAs a senior member of the Facility Compliance Review team at Blue Shield of California, you will play a critical role in ensuring that post-service prepayment facility claims are thoroughly reviewed for contract compliance, industry billing standards, medical necessity, and hospital-acquired conditions/never events. Reporting directly to the...

Job SummaryThe Clinical Review Specialist, Senior at Blue Shield of California will lead retrospective utilization reviews and first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare and FEP.Key...

OverviewAt Blue Shield of California, we are committed to delivering high-quality healthcare services. Our Utilization Management team plays a vital role in ensuring that our members receive the best possible care.In this exciting opportunity, you will work as a Clinical Review Nurse, Senior - Utilization Management, and be responsible for reviewing medical...

**Overview of Blue Shield of CaliforniaWe are a not-for-profit health plan that provides high-quality healthcare services to millions of Californians. Our mission is to make a meaningful difference in the lives of our members by delivering innovative, patient-centered care.About the RoleWe are seeking an experienced Clinical Review Specialist - Utilization...

About the RoleThe Facility Compliance Review team reviews post-service prepayment facility claims for contract compliance, industry billing standards, medical necessity, and hospital-acquired conditions/never events. As a Utilization Management Nurse, Senior, you will report to the Senior Manager, Facility Compliance Review.

Job Summary:Molina Healthcare Services works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum. This includes behavioral health and long term care for members with high need potential. Our staff work to ensure that patients progress toward desired outcomes...

Job OverviewThe Medical Claims Review Specialist will be responsible for reviewing facility claims to ensure compliance with medical necessity and billing standards. This role involves conducting retrospective utilization reviews, preparing cases for medical director oversight, and ensuring adherence to regulatory and accreditation requirements.Key...

Job Summary: Molina Healthcare Services works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. Our goal is to ensure that patients progress toward desired outcomes with...

Job SummaryWe are seeking an experienced UM Nurse, LVN to join our team at Advanced Medical Management. As a key member of our utilization management team, you will play a critical role in ensuring that our members receive the highest level of care while also helping us optimize resource allocation.In this role, you will be responsible for conducting...

Job Title: Clinical Nurse LeaderWe are seeking a highly skilled and experienced Registered Nurse to join our team as a Clinical Nurse Leader at the Kei-Ai Los Angeles Healthcare Center.About Us:The Kei-Ai Los Angeles Healthcare Center is a premier nursing facility dedicated to providing high-quality care to our residents. We strive to create a warm and...

Job Title: Clinical Audit Specialist**Salary:** $70,000 - $90,000 per yearWe are seeking a skilled Clinical Audit Specialist to join our team at Molina Healthcare. In this role, you will be responsible for supporting the prevention, detection, investigation, and reporting of healthcare fraud, waste, and abuse.Key Responsibilities:Perform accurate and...

Job Title: Clinical Nurse SpecialistFifth Commandment Healthcare Staffing, LLC is seeking a highly skilled Clinical Nurse Specialist to join our team. This role requires 2 years of acute care experience, with a focus on Cardiac Telemetry.Salary:$80,000 - $120,000 per yearJob Description:We are looking for a dedicated and compassionate nurse to work in a...

About the RoleAre you a detail-oriented healthcare professional with a passion for delivering high-quality care? Blue Shield of California is seeking a skilled Clinical Coding Analyst RN, Senior to join our team. As a member of our Facility Compliance Review team, you will play a critical role in ensuring the accuracy and integrity of medical coding for our...

Job Title: PICU Clinical Nurse SpecialistJob Summary:Fifth Commandment Healthcare Staffing, LLC is seeking an experienced PICU Clinical Nurse Specialist to join our team. As a PICU Clinical Nurse Specialist, you will be responsible for providing high-quality patient care and leading the nursing team in the Pediatric Intensive Care Unit.Key Responsibilities:-...

Role Overview:The Clinical Coding Analyst RN Senior will be responsible for performing in-depth quality audits of hospital claims to support ICD-10-CM and ICD-10 PCS codes, as well as MS-DRG and APR-DRG reviews based on clinical determination. This role requires a strong understanding of medical necessity and reimbursement requirements, as well as the...

New Heritage Recruiters, Inc. is seeking a skilled Clinical Supervisor to oversee the clinical and support services of their assigned team.Key Responsibilities:Ensure culturally competent mental health services to clients through supervision of associatesProvide training, supervision, and guidance to ACSW, AMFT interns and trainees in MSW, MFT programs, and...

OverviewIncredible Health is actively seeking a skilled Registered Nurse to fill the position of Clinical Nurse Specialist - Infusion Leadership in Long Beach, CA.Job Summary:This role entails providing guidance and support to infusion teams, promoting best practices and ensuring exceptional patient care. The ideal candidate will possess experience in...

About TotalMed StaffingTotalMed is a leading healthcare staffing agency with a mission to provide top-notch clinical professionals to facilities nationwide.We are dedicated to igniting purpose in healthcare by matching skilled caregivers with the right organizations to ensure exceptional patient outcomes.Job OverviewTotalMed is seeking an experienced...

Job Title: Senior Clinical Nurse Case Manager - Federal Employee ProgramOverview:The Blue Shield of California team seeks an experienced and skilled Senior Clinical Nurse Case Manager to join our Federal Employee Program. As a Senior Clinical Nurse Case Manager, you will be responsible for conducting comprehensive assessments, developing care plans, and...